"Rationality & Welfare: Public Discussion of Poverty and Social Insurance in the United States 1875-1935"

by Professor Theron Schlabach

"In the midst of the present social upheaval," wrote the editor of The Journal of the American Medical Association pensively in 1926, one may well wonder the position physicians will eventually occupy in the cosmic scheme,1 In his one sentence the editor reflected the contradictory moods in which the medical profession wrestled with the question of social insurance, particularly health insurance, in the years leading up to 1935. In some moments, physicians and others in the medical field were insecure, uncertain about themselves, their profession, and the future direction medical practice should take amid the general developing and structuring of America's social institutions. At other times they exuded confidence that their judgments on the matter were broad and valid, that they alone should decide every issue touching medical affairs. To have or not to have health insurance was, however, only a small part of the issue that evoked the medicos' mixture of emotions. It was but one subpoint in a much larger debate over how medicine might be reorganized.

The debate did not take on urgency until 1915, when the profession became alert to a model health insurance bill that the American Association for Labor Legislation was about to press upon state legislatures. Health insurance, which Germany had initiated in 1883, had been prominent in the suggestions of virtually all the writers who introduced social insurance to America and in the 1912 reform programs of the NCCC and the Progressive Republican party. After the drive for workmen's compensation about 1911, reformers began seriously to promote health insurance, partly as a logical answer to the difficulty of defining and including occupational diseases in workmen's compensation. Most of the discussion centered around the efforts of the AALL, which for several years engaged in research and put forward tentative suggestions and then in November 1915 and January 1916 published tentative drafts of a bill. The January draft provided for compulsory coverage of all industrial workers earning less than $1260 and a combination of medical, surgical, hospitalization, and cash benefits, including funeral benefits in case of death. Various kinds of local, district, or state funds organized on a non-profit basis might carry the insurance, under state supervision. The employer and the employee were each to pay 40% of the premium, the 40% amounting to about 1,5% of the wage payment, and the state the remaining 20%, In 1916 there began a bitter, though in the end unsuccessful, battle in the New York legislature for passage of the AALL bill that lasted for four years. Meantime lawmakers in eight other states, California, Massachusetts, New Jersey, Connecticut, Illinois, Ohio, Wisconsin, and Pennsylvania, appointed eleven different commissions to study the subject, of which six reported favorably, though also without success.2

At first the medical profession seemed willing to cooperate. The AALL had consulted medical opinion by including in its social insurance committee Dr. Alexander Lambert, prominent New York physician, Professor of Clinical Medicine in Cornell's medical school, and chairman of the AMA Judicial Council; and Dr. Sigismund S. Goldwater, New York City Commissioner of Health and Director of Mt. Sinai Hospital. At the annual meeting of the AMA in July of 1915 Lambert and his Judicial Council produced a lengthy report on social insurance in general which, though avowedly presenting the subject only from the educational point of view, was a resounding apology for the reform. The AMA Journal followed with editorial support. In January, 1916, after the journal had called for wider cooperation from the profession, the AMA formed a special Committee on Social Insurance--again with Lambert as chairman--which immediately collaborated with the AALL to draft the new version of the health insurance bill. The committee soon appointed a prominent propagandist for social insurance and AALL member, Isaac M. Rubinow, to be its Executive Secretary. In 1916 and again in 1917 it presented more highly favorable reports to AMA conventions. To be sure, in its 1916 report the committee once more avowed, quite speciously, that it was not arguing for or against health insurance; and it never recommended that the AMA endorse health insurance outright, only that it continue to cooperate in the framing of health insurance bills. But with the Lambert-Rubinow team not only issuing favorable reports, but also working constantly with legislative commissions and other groups, the AMA effectively gave the reform a great deal of support.3

Health insurance advocates found further support among others of the medical profession. Benjamin S. Warren, a high official in the United States Public Health Service spoke out boldly in their favor. The American Journal of Public Health, organ of the American Public Health Association, observed in April of 1916 that organized public health was behind the movement, and a month later a conference of state and territorial health authorities unanimously concurred. At its annual meetings from 1916 to 1919 The American Hospital Association carried on a vigorous discussion that was, on the whole, decidedly favorable. Dr. Thomas Howell, Superintendent of New York Hospital in New York City who in 1918 reported on behalf of the hospital association's Committee on Health Insurance, was unequivocal in his endorsement, as was the association's executive director, Dr. Andrew Warner of Chicago. The Modern Hospital,prominent mouthpiece of hospital administrators, added firm editorial support. The Journal of Sociologic Medicine approached the subject more gingerly, yet was receptive to the idea and gave a special column to social insurance throughout most of 1916 and all of 1917. The Journal's parent organization, the American Academy of Medicine, was even more cooperative. It included the AALL's Executive Secretary, John B. Andrews, in a Committee on Social Insurance, which reported in 1917 with complete enthusiasm. 4

Yet for the advocates, the drama ended in tragedy. In May 1916, after a string of favorable comments, the AMA Journal suddenly lapsed into a virtual editorial silence on the subject for ten years. Midway in 1917 the profession's most dashing warrior suddenly abandoned the battle, conducted an emotional session of the AMA to rally his colleagues' patriotism, and as Major Lambert of the United States Army marched off to Europe and a different war. The AMA honored Lambert by making him its president in 1918; but it rejected his ideas on health insurance in terms that left no doubt. In 1920 the AMA delegates resolved that the American Medical Association declares its opposition to the institution of any plan embodying the system of compulsory contributory insurance against illness, or any other plan of compulsory insurance which provides for medical service to be rendered contributors or their dependents, provided, controlled, or regulated by any state or the Federal government.5 Among other elements of the profession the tragedy did not always end so sharply. The idea simply disappeared. The effect, however, except for the dramatics, was the same.

If the AALL wished to depend on medical men for support, it should have taken note of extensive softness in its allies lines. Sabotage from opponents within the medical profession was an ever-present threat. The opponents' objections ranged from the valid analysis that health insurance would not benefit the poorest of people, since the casually employed and the unemployed often would not qualify for benefits; through bromidic assumptions that taxes and bureaucracy would become unbearable, and that the system could not help but destroy professional standards; to the cry, amid World War I, that health insurance was a brainchild of German tyranny. Even opposition writers who scored some well-taken analytical points frequently set them in a context of social fundamentalism that charged wage earners with spending too much on movies and rum or that found the reform to be nothing more than a new type of poor relief that would pauperize recipients, subvert American ideals, damage public morals, coddle wage earners, and destroy individual initiative.6 Yet the opposition from opponents was not the only softness in the medical profession's support. The supporters used doubtful strategy.

Almost universally, health insurance advocates within the medical profession rested their appeal to their colleagues on the premise that health insurance would come regardless of the profession's stance, so that the only rational course was to cooperate. It was the certainty that such laws will be enacted within a few years, the AALL's previous legislative successes, and its willingness to consider the wishes of the medical profession that had convinced AMA officials that cooperation is desirable and opportune, editorialized the AMA Journal in December of 1915. Medical men who opposed health insurance, declared the AMA committee eighteen months later, were like old King Canute sitting on the seashore bidding the rising tide to stop. But the argument of inevitability had a strategic weakness. It was plausible only so long as the tide seemed to be running toward the reform. After about 1917 the tide began to reverse. One might as well say that bolshevisim or anarchy or Mohammedanism are bound to come, must because they came to other countries," declared Malcolm L. Harris, nationally-known Chicago surgeon, in 1920.7

The supporters coupled their inevitability argument closely with what became the most explicit note in the medicos' discussions, a shameless concern on the part both of advocates and of opponents for professional self-interest. The AMA Journal added to its December 1915 call for a operation the clinching argument that this close cooperation will guarantee that the best interests of the medical profession under health insurance will be borne in mind at every step, and the AMA committee added to its King Canute analogy the reminder that King Canute only got wet for his trouble. From the 1915 AMA Judicial Council report and countless other sources, medical men knew of the struggles between physicians and insurance funds in Europe around questions of the patient's ability freely to choose his physician, of representation of the doctors on the funds' governing boards, and of the bases upon which the funds would pay physicians.

When the AMA Committee on Social Insurance began its work early in 1916, therefore, it declared explicitly that, in addition to educating the profession and acting as a clearing house for information, its duty was to protect the legitimate economic interests of the profession in the laws coming up for discussion.8

Though subsequent AMA committee reports managed to weigh professional interests judiciously with those of the patient and the public, much of the discussion within the profession did not. At the outset The Journal of Sociologic Medicine remarked petulantly that it would be remarkable if the same care were bestowed upon the welfare of the physician as upon the comfort of the workingman. The American Hospital Association's health insurance committee report in 1918 showed much more inclination to ponder the large possibilities for increased revenue under health insurance and to speculate in glowing terms of paid staffs and supplementary equipment for hospitals than desire to structure the system for maximum benefit to the wage earner.9 In many such expressions the professional self-concern remained within the bounds of the legitimate only if one assumed a priori a total identity of interest between profession and public.

In their haste to discuss and appeal to the profession's own welfare, medicos who favored social insurance neglected what had finally to be the fundamental rationale for the reform, the economic and medical welfare of people of limited income. To be sure, they did not ignore such considerations completely. From time to time they invoked what was, in the words of one doctor, the almost axiomatic fact "that disease entails poverty and poverty entails disease. Or they quoted figures on the high incidence of sickness among the poor, or pointed out how heavily the wage earner depended upon continued good health for income. Even more to the medical point, the AMA Journal editor in his initial endorsement of health insurance in 1915 cited the more efficient medical care which a system of health insurance would provide, declaring that under British health insurance many persons for the first time were able to afford the luxury of medical attention, and for the first time physicians were able to treat disease in its incipient stages among the industrial population.10 But though the advocates had such arguments at their pen tips, they made them only in a scattered and incidental fashion.

Especially ironic was the failure of medicos championing health insurance to develop extensive and systematic treatises resting on explicitly medical criteria. Closely connected with the AALL, Lambert and Rubinow produced reports for the AMA that were hardly distinguishable in essential content from AALL releases or Rubinow's other writings. Their 1917 report did not even confine itself to health insurance, but ranged over the entire social insurance field. The report of the American Academy of Medicine's committee, with Andrews as a member, similarly lacked a specifically medical approach.ll Advocates often appealed to the medicos' professional self-interest on matters of payment, control, and free choice of physician. But they did not build strong appeals to the judgment of the physician as a man of science who was committed to giving the best of medical care to all.

Some of the medicos tried to tie health insurance to high medical standards by asserting its potency as a preventive of disease--countering opponents' frequent argument that preventive medicine was the alternative to health insurance, and that the state had better direct its efforts to its more proper task of promoting sanitation and public health. In 1917 the AMA committee tried to assure the profession that the great subjects of preventive medicine and sanitation shall be written in these [health insurance] laws and shall form a part of them. Others made preventionism even more central. Dr. Ira S. Wile, a New York physician, lecturer, writer, philanthropist, and a rare figure who argued for health insurance from a distinctly welfare point of view, wrote in 1916 that health insurance was more than "merely a relief system." It was a method of putting a financial penalty on ill health. Wile predicted that the reform would change the viewpoint of physicians from the pathological, which places a premium for them upon disease, to the more normal and rational view of payment received for the maintenance of health. Wile rested his arguments on the premises that health constitutes an asset of the State and the general raising of the standards of health of a community was more important than the mere cure of individuals. It was on similar premises that public health officials supported health insurance. Warren of the U. S. Public Health Service wrote in December, 1915 that the essential principle of sickness insurance was to introduce a collective device to lower the cost of disease by promoting prevention, and others in his profession concurred.12 Such language represented an attempt to tie health insurance to high medical standards by stressing prevention.

But the emphasis on prevention was scarcely half the argument. The other half was that among the criteria for high medical standards availability and quantity of medical treatment should have had a high place. The proponents failed to make that argument systematically, and on the whole lost an opportunity to tie their reform closely to the sacrosanct principle to which all medical men made obeisance, high and scientific standards of treatment.

The words of Warren and the public health officials represented another trend: the health insurance campaign gave each group within the medical profession opportunity to advance its own hobby and jockey for position. Warren and the public health officials tied their preventive emphasis closely to a proposal to place the administration of medical benefits directly under government agencies, with a corps of medical officers to oversee and act as referees of the entire system. Their proposal, of course, would have given vast new powers to officials of their own kind. In similar spirit Mary E. Lent, Associate Secretary of the National Organization for Public Health Nursing, declared in 1917 that we have been looking forward most eagerly to a sane health insurance plan which in its administration will include the public health nurse as an important factor in its development. Hospital spokesmen moved to secure their position. Some workmen's compensation systems had angered hospital administrators by paying only such fees as hospitals normally charged individuals, even when the fees did not nearly represent the complete cost of a services. Discussions at the American Hospital Association quite understandably emphasized that health insurance should be structured to cover the complete cost of treating the patient. The report of the Association's health insurance committee in 1918 went much farther, and invoked visions of hospitals being given funds with which to undertake long desired improvement. According to the report, the health insurance system must be so organized as to offer the hospital the fullest possible opportunity for useful development and expansion. Indeed, it advised, it is scarcely an exaggeration to say that, if the hospitals are alive to them opportunity, they should develop into the hub of the health insurance system.13

The AMA committee rejected the public health man's referee suggestion as too likely to result in political control and loss of local autonomy, Editorials in The Modern Hospital criticized physicians for making the patients free choice of physician an absolute right, defended a hospital's right under health insurance to require the patient to be treated by the hospital's own` medical staff rather than by his private physician, and insisted that the patient should have the right to choose treatment in such a hospital rather than from a private practioner. Public health officials, for their part, suggested payment of physicians on a capitation basis (a flat annual fee for each insured person for whom the physician was responsible, regardless of whether he required treatment or not) as most likely to advance the preventive medicine approach.14 Any limitation of free choice and payment by capitation were both utter anathema to physicians in private practices Thus differences in purpose and jockeying for position among the various elements of the medical profession assured that there would be conflicts, if not over the principle of health insurance, at least over structural detail.

About 1917 the principle itself came under increasingly heavy attack. This time it was primarily private practioners who were solicitous for their position. The editor of the AMA Journal spoke with well-placed concern when in May, 1916 he urged that in order for the profession to speak with one voice individual physicians and medical organizations refrain from isolated active efforts before legislatures, pro or con. The fact was that the AMA Social Insurance Committee did not speak for grass roots medical opinion. Its reluctance to recommend that the AMA's governing body, the House of Delegates, endorse health insurance outright was a virtual admission of that fact. At a 1917 conference Lambert admitted that eighty percent of physicians opposed the measure, and other medical. men in attendance agreed with his estimate, Nor were the few supporters a representative cross section. Eden V. Delphey, leader of powerful opposition in New York, had plausible grounds for fearing that the physician who would get a position of influence in the health insurance system may be one who has never practiced medicine; or he may have done so for a few years and then quit for a more congenial and lucrative business; or he might have practiced only among the wealthy and come into contact with the poor only in hospitals and dispensaries. The measure's medical proponents were indeed most often professors in medical schools, public health officials, and hospital administrators--men who Rubinow later observed were either very successful and far above any fear for their own economic future or professional standing or in other ways far removed from the system of private medical practice.15

Such men were articulate and able to dispense their opinions quickly, but the grass roots doctors were more formidable once they mobilized. The Chicago Medical Society spoke well for the rising opposition when in March of 1917 it published thirty-four objections--a few of them valid analyses but more of them simply variations on the slogans of a laissez faire social fundamentalism-- designed to crush any argument for health insurance. In New York state, where most of the medical support for health insurance centered, a Physician's Protective League of Erie County lashed out with arguments ranging from attempts to prove statistically that health insurance countries had higher death and infant mortality rates and longer average periods of illness than did the United States to assertions that the reform was part of a of social insurance chain, forged by Bismarck, in a monarchial smith, to stake the worker to the soil.

In the New York City area a special committee of the local county medical society first intended to endorse health insurance and then, in 1917, decided upon a neutral position. Thereafter a bitter opponent, Dr. Eden V. Delphy, won control of the committee and had it declare health insurance an iniquitous scheme which could but have a serious and destructive effect upon the most altruistic profession on the face of the earth. Similarly the New York State Medical Society's committee to study the matter returned a neutral report in 1917 even though its chairman, Dr. Samuel J. Kopetzky, was an ardent supporter; and by 1919 a new committee under the chairmanship of a Buffalo (Erie County) physician, Harvey R. Gaylord, returned a strong opposition report which the State Society adopted in a special session. Meantime criticism of the AMA's failure to condemn social insurance forthrightly mounted upward from the grass-roots and state levels, culminating finally in the AMA delegates unequivocal opposition resolution in 1920.16

Had the medical men merely done what Devine acidly accused them of, marshalled their political power not in order to serve, but in order to protect their pocketbooks?" It was not so simple. Certainly there was evidence to make Devine's charge plausible. Writing explicitly from the point of view of the general practitioner, Delphey in 1916 declared that the question of remuneration under health insurance was not an altruistic one, since the insurance would not cover the poorest patients anyhow, and warned his fellow doctors to fight for their professional financial life. Others agreed with New York dermatologist Dr. William S. Gottheil that physicians, being a small and helpless class would have to do much of the work and make most of the sacrifices under health insurance. As consumers, Gottheil argued, doctors would have to help pay the payroll taxes which employers and labor would succeed in passing on; as taxpayers, they would help pay the state subsidy; and as practitioners they would still have to treat on a charitable basis those poor who would not qualify for insurance benefits. And they could also expect parsimonious managers of insurance funds to hire doctors for routine cases on a salary rather than on a fee basis, and to cut the fees of specialists to a minimum.17

Seemingly however, the opponents did not fear a general loss of income so much as loss off opportunity to make very large incomes and become rich. AMA officials and other advocates argued that health insurance promised to increase the average income of physicians and to make income more secure, by directing more total wealth to medical care and by reducing the number of charity cases and uncollected bills. Yet implicitly they admitted that there would be a leveling of physicians incomes. In 1915, for example, Lambert's Judicial Council pointed out that workmen's compensation systems had required medical specialists to keep their fees at reasonable levels. In 1916 Emery R. Hayhurst, of the Ohio State Board of Health, admonished in an argument for health insurance that standards of payments derived from service among prosperous families . . . cannot be applied to the treatment of the great class of wage-earners. The doctors who opposed health insurance sometimes conceded that average incomes might increase, and though they did not argue crassly that they had the right to get rich, occasionly they dropped a hint that suggested opposition to a leveling of incomes. Under health insurance, declared the Chicago Medical Society report of 1917, it will be the least efficient doctors who will make the most money."18

Although the opponents held apprehensions on economic grounds, the economic issues were ambiguous. A more stable basis of their opposition lay elsewhere, in the frequent implication that practice under health insurance would be degrading. As Delphey and his New York County committee put it, health insurance would tend to destroy individuality and prevent the proper class of men from entering the profession. Discussants at the public health section of the 1919 NCSW conference more or less agreed that physicians usually opposed because they feared that the medical profession would suffer a loss of dignity.19 Such expressions were but hints of the larger issue that health insurance evoked, the question of what status the profession would have after the larger American social system had reached some new equilibrium in its process of structuring and institutionalization--the profession's place in the cosmic order after the social upheaval.

At bottom the conflict was more social than economic, a fact that the advocates who appealed so openly to medical men's self-interests almost completely overlooked. The AMA social insurance committee; promised to protect the profession's legitimate economic interests. But Lambert championed a reorganization of medical practice.20 And it was as the health insurance issue got intertwined with the larger question of medical reorganization that it evoked the deepest disagreements. More and more it became only a small part of that larger, very troublesome question.

Throughout the entire period from 1915 to 1935 there was no more persistent champion of medical reorganization than Micheal M. Davis, Director of the Boston Dispensary until 1920, Secretary of the New York City-based Committee on Dispensary Development from 1920 to 1927, and thereafter the Julius Rosenwald Fund's Director of Medical Services. In Boston in 1913, and in New York City in 1921, Davis organized pay clinics for people of low income. He noted that in Great Britain and in Germany health insurance had vastly extended the reach of medical practice among the low income classes, and favored that reform also. But, he wrote in January of 1916, the foreign systems were deficient because neither did enough to advance co-operatives or group patterns in medical practice. In the United States, he hoped, if a system of sickness insurance is to provide medical service for a large part of the working population on the financial basis provided by insurance payments, surely the medical organization of the system ought to be in line with the most advanced forms of medical work; or at least the system should contemplate development in that direction.21

Being convinced that the best examples of medical service were to be found in the best hospitals and dispensaries, Davis wanted medicine to move beyond the stage of individualistic private practice. Other health insurance advocates joined his cause. The individualistic system with its individual doctor, its individual patient is passing, declared George A. Hare, a Fresno, California practitioner, at a 1916 meeting of the American Academy of Medicine where he was elected the Academy's president. And he thought that in the transitional period health insurance would be a means for the prevention and the cure of sickness on a collectivistic plan, just as society now prevents and cures ignorance by means of our public schools. In 1920 the social worker Devine put the issue succinctly. Medical men were deliberately rejecting a system of practice that was organized, socialized, and modernized he declared, for one that was chaotic, anarchistic, individualistic.22

When Devine and doctors who favored health insurance used the term socialized, they were referring to cooperative, group forms of practice, not particularly to government control. Hayhurst of the Ohio State Board of Health, arguing for health insurance in 1916, declared tersely that the socialization of medical service must come and used the phrase synonomously with an intensive organization of medical service. Socialization, wrote Dr. Donald B. Armstrong of the National Tuberculosis Association in 1920, means the scientific treatment of all illness, the availability to all of existing instruments for diagnosis and treatment, and the progressive decrease of the cases that go untreated altogether, scientifically or otherwise.23

Along with Armstrong zealots for reorganization (or socialization) almost universally advocated their reform as a way to apply medical science. It was the means to specialization, and not to reorganize seemed hardly an option. With the progress of medical science, Dr. James L. Whitney of San Francisco told his county medical society in 1916, no longer can one person be sufficient to the treatment of a patient. The general practiser [sic] requires the assistance of the laboratory physician and those who are following the various specialities to assist him in the diagnosis and the operating surgeon to assist him in treatment. Davis argued on similar grounds, and added the factor of efficient utilization of expensive medical equipment.24 Both men, and many others of similar persuasion, favored health insurance primarily on the grounds that it would be the means to enable patients to pay for the vastly improved and more complete medical service reorganization would bring.

In contrast to the lack of coordination between the family doctor and specialists who served a patient as individual practitioners, Davis noted, a specialist system plus organization was emerging in hospitals and dispensaries.25 That hospitals and dispensaries might advance in status to leadership in medical innovation was a third thread running through the interwoven issues of health insurance and medical reorganization. Dispensaries were organized almost completely to give free treatment to the poor, and hospitals also still had about them much that reflected their origins as charity institutions. But, wrote Wile of New York in 1916, the establishment of health insurance would necessarily alter the type of dispensary practice, ending both free service to many patients and the practice of not paying physicians for dispensary work. Hospitals themselves, Wile predicted, would be better controlled and organized so as to provide the most modern equipment and diagnostic facilities for the use of physicians in the interest of patients. Instead of philanthropic agencies that frequently lost contact with the patient before recovery was completed, hospitals would become scientifically managed institutions for the reestablishment of the health of those making use of them.26

Such predictions formed a substantial part of discussions of health insurance, particularly among hospital dispensary, and clinic administrators. The administrators saw the prospect of entirely new mixes of patients, and of practice, with general practitioners taking on the many routine cases that free dispensaries were treating because the patient could not pay, and dispensaries and hospitals graduating to cases requiring special diagnosis and treatment. They were also confident that hospitals and dispensaries would increase in number, providing more cure for less money. In each [health insurance] district there would be a thoroughly organized dispensary with a competent paid medical staff, nurses, and a social service branch, declared J. Whitridge Williams, Dean of Johns Hopkins Medical School and ex-Director of the Johns Hopkins Dispensary. If possible the dispensary would be attached to a hospital, but in any case it would became the community health center. The fact that greater efficiency and economy can be obtained through organization in hospitals and group clinics, observed an editor of The Modern Hospital, will mean that such organizations will gradually acquire more and more of the practice under any system of supervision which health insurance would require.27

The tragedy for health insurance was that by tying it to such discussions and predictions, its advocates rubbed a burning potion into what had lately become for private practitioners a painful infection. The establishment of free dispensaries in the United States had begun in New York in 1771 and continued slowly, with no more than 150 such institutions in existence in 1900. But from 1900 to 1915, under the impetus of the public health movement and a wave of general hospital building, the number had increased seven fold. Although physicians found the dispensary a convenient place to treat their non-paying patients, they grew more and more disturbed at the number of people who sought its free care. In the late nineteenth century and continuing, they frequently objected, raising COS-type complaints regarding pauperization and indiscriminate charity. By 1915 medicos tripped off the term dispensary abuse as a self-evident truism. In an effort to define the phrase Williams observed that general practitioners in the less prosperous areas complained of losing fees when people who, though in moderate circumstances, could pay used the institutional facilities. Again, young specialists complained that the same persons were getting operations free of charge. Williams replied that such people used the free facilities to obtain better, more scientific treatment more than to escape payment.28 But his reply hardly allayed the complaints.

Quite early COS spokesmen had proposed to substitute for the free facilities provident dispensaries, which by a rudimentary type of insurance would offer complete medical services in return for a small flat weekly payment.29 Medical men, however, were slow to take up the suggestion. The scheme smacked of contract medicine, a term which implied forms of medical organization which to independent practitioners were even more abhorrent than free dispensaries: wholesale agreements to provide medical services to the employees of a large firm, the poor of a town, or members of hospital associations (discussed by doctors as promoters schemes); payment by salary or capitation rather than by fees for particular services rendered; and lodge practice, whereby fraternal organizations got physicians to provide members' medical care at severely reduced rates. Ten-cent doctors was the derisive term for physicians who practiced contract medicine.

Without question the doctors had cause, indeed a responsibility, to look at new forms of organization critically. The physician, observed the AMA Judicial Council in 1915, knew that under contract he is liable to be pushed to the commercial limit irrespective of services given, and that the over-burden in numbers of patients and amount of work would soon result in a deteriorated service. But some of their criticisms were less than substantial. Apparently they went beyond rejecting the more degrading forms, and extended to legitimate forms of medical reorganization. At least Rubinow, who in addition to being an actuary and a prolific propagandist for social insurance held an M.D. degree and had practiced medicine for five years, thought so; he sensed in addition to physicians' noisy opposition to dispensaries and 10-cent doctors a silent opposition to extension of hospital facilities. It rested, he believed on apprehension toward any inroads into the field of private practice.30

Sometimes medicos who favored health insurance tried the tactic of arguing that health insurance would forestall the growth of contract practice. After expounding on the wickedness of company doctors, hospital associations, and lodge practice, Emmet Rixford, Professor of Surgery at Stanford University, asserted that sickness insurance would check such evils and put a premium on better quality of medical and surgical practice. Wile made the very fundamental point that workers sought contract arrangements despite their low quality of medical care precisely because there was an economic problem. The vicious circle of underpaid, overworked lodge doctors and inadequate care, concurred the AMA Social Insurance Committee in 1916, is formed by certain economic situations, and this circle cannot be broken except by a change of the economic forces. The committee believed that compulsory insurance by the state can alone solve these economic problems of the very poor and release the unfortunate physician who, facing starvation, must accept this lodge practice.31

On specifics, however, health insurance supporters equivocated. Davis thought the insurance societies ought to be allowed to contract with a dispensary or hospital for medical services, provided the physician in the institution received the same compensation as individual practitioners. Wile also was willing to contemplate contracting under certain conditions, and payment of physicians on a salary basis as well. Another issue was that of allowing the patient free choice of physician, in order directly to preserve a personal relationship and the essence of individual practice; and on that also health insurance supporters sometimes wavered. Hayhurst of the Ohio health board thought completely free choice unlikely as this is based on the theory that the patient is a better judge of a service's ability than are those who are in a proper position to know. Warner of the American Hospital Association denounced as absurd the tendency of the general practioner to look upon the persons who seek his advice as my patients regardless of the needs of these patients or his own professional ability to render the service needed.32

The AMA committee showed a healthy interest in the devices for protecting the individual practitioner. In no uncertain terms it condemned lodge practice and all that resembled it. It took for granted the basic device in the AALL for preserving the essence of private individual practice under health insurance, the panel system (whereby duly qualified physicians in a given locality who chose to work under the local insurance fund would enroll to form a panel of physicians from whom a patient could choose his personal physician; the physician, in turn, building up his own panel' of patients). The committee did not try to avoid the troublesome issues, and finally by 1917 it settled upon four basic principles that medical men should demand: freedom of choice of the physician by the insured; payment of the physician in proportion to the amount of work done rather than by flat fees, capitation, or salary; separation of supervisory functions from treatment in a manner to minimize conflicts between the attending physician and the insurance carrier; and adequate representation of the medical profession on the appropriate administrative bodies.33

Nevertheless in the discussions leading up to its four principles, the committee found it necessary to build in qualifications. Its 1916 report qualified endorsement of free choice with the observation that there would have to be limitations on the number of patients in a physician's panel, lest the system produce the overworked doctor of lodge practice. On the manner of payment, the committee favored the visitation system, i.e., fees based upon the number of visits to patients and graded according to the service given. Yet it recognized that the system could tempt physicians to make unnecessary visits and increase indefinitely the costs of insurance; and Lambert even favored a qualification that would have provided one total sum that the physicians on the panel would have to prorate among themselves according to the services that each had rendered. This, Lambert thought, would protect the funds and in addition induce doctors to discipline one of their own when he became dishonest. Lambert's committee also openly expressed the need for physicians to accept some disciplining by committees of fellow doctors, as well as arbitration of disputes with the insurance carriers. Finally it recognized the limitations of its fourth demand, medical representation in administration, by waiting of the need to reconcile the conflicting interest of the three relevant groups, the insurance carriers, workmen, and physicians.34

Despite that qualification, the committee placed its main faith not in specific structural features but in its fourth principle--representation of medical men in administration. Warning that the profession had to take hold of the issues if it was to obtain the justice that is due it, if it is to, protect its economic position in the community, the 1917 AMA report declared that the committee feels very strongly that the members of the medical profession are the only ones who can solve the problem of medical service under these social insurance laws.35 But reliance on medical representation in decision-making posed two problems, from the point of view of protecting individual practice. It raised the question of whether those who had the power to speak for the medical profession truly represented the independent practitioner. Indeed, it virtually forced the medical profession to an internal fight for the right to speak. Secondly, it offered no assurance that those in control would work to preserve as far as possible under health insurance the existing forms of medical organization. The representatives might choose the alternative path of accepting changes in those forms, and working only to assure that the physician's position was viable after the changes.

And the AMA committee chose the latter path. It was very friendly to the development of group medicine. At its outset it pronounced an intention to undertake a statistical study of hospitals and dispensary facilities in this country in view of the possibility of these institutions assuming a broader function under health insurance. Though as yet dispensaries and hospitals were mainly institutions for providing free medical care to the poor, declared the 1916 report, a well-conducted and well-organized dispensary offers the most economical and efficient method of giving to the patient the many specialized medical services that the varying nature of their illnesses may require. In its 1917 report the committee referred approvingly to the dispensaries very thorough pathologic work and work of clinical microscopy, their growing practice of follow-up care in patients homes, and their specialization, calculating that general practitioners were equipped to treat no more than 27.4% of the cases dispensaries were handling. Cautious, it did not commit itself explicitly to the idea of group practice beyond the observation that there was gradually developing on a charity basis a social development of medical care that could be occurring instead under health insurance. Lambert personally, however, was more outspoken. Under health insurance, he argued, dispensaries will be a boon because they will develop into the best examples of group medicine. . . . A reorganization of the basis on which physicians do their work in municipal hospitals, and even in private hospitals, would have to take place. The new role of dispensaries and hospitals, he thought, offered not only a better method than is now in vogue, but also the very scheme through which medicine is developing and through which it is bound to develop in the highest degree in the near future--that of group medicine.36

Thus the intermixing with the group medicine issue added to health insurance a great onus. To the physician convinced that reorganization of medicine was necessary on grounds of economics and medical science, it of course made health insurance more attractive. But to the medico who was committed to the preservation of an individualized and independent pattern of practice, the discussion was desultory and threatening. The health insurance advocates told the practitioner that he was no longer qualified in the large majority of cases. They lauded the very dispensaries which he had long accused of taking patients who could pay if they would, his sources of income. They wrote of a new mix of patients whereby dispensaries and hospitals would get more of the interesting cases on the one hand and of the well-to-do on the other, leaving him with more of the routine and of the unbathed lower classes. They muttered the right phrases against contract practice and for free choice of physicians, yet when pushed to specifics they showed an ominous willingness heavily to qualify or even to contradict those phrases. Even his supposed representatives in the AMA equivocated, and instead of forthrightly protecting individual practice invited him to put faith in them to protect his interests while giving him reason not to. They supported group medicine.

The physicians opposition was not simply a case of preferring private enterprise over governmental action. Quite truly as Americans moved politically out of the progressive era to the conservative twenties medical men inveighed ever more frequently against the invasion of government into medicine, and anti-governmentism got more and more confused with anti-organizationism in the idea of medical socialization. Yet the Federation of Medical Economic Leagues, which became a firm base of opposition in New York, opposed health insurance by commercial companies for profit before it rejected the state health insurance bill. No less an opponent than Delphey indicated that his opposition was more to organization than to state action. If individual health is proved to be a state asset, he argued in 1917, then the state should pay the entire cost of the care of all the sick. It could do so better and more cheaply simply by paying for medical attendance and treatment, than by the complicated, cumbersome, top-heavy, and dangerous scheme proposed under the standard bill. And as it became more hostile the AMA Journal was almost as skeptical of the growth of privately-organized group clinics as of governmental action. Does it mean that the family physician is being replaced by a corporation, asked the Journal's editor in 1921. Would not the average layman . . . prefer state medicine?37

Nor was the physicians opposition simply a matter of accepting the values of a business civilization. It was the advocates of group medicine who spoke the language of efficiency minded business. It sounds very unsentimental and businesslike, argued Dr. Richard C. Cabot of Boston, chief of the Massachusetts General Hospital Medical Staff and professor at Harvard, but if we are going the old system of peddling medicine from house to house, the most inexpensive and ineffective method that can be conceived. Businessmen, being the most avid reorganizers of Americas institutions, agreed. The medical profession needs more effective organization, declared A. Parker Nevin, General Counsel of the National Association of Manufacturers, in 1916. the opponents of health insurance, by contrast, frequently expressed fear of corporate or commercial principles in medicine. Superorganized, big business methods, exaltation of mass production and delivery with the submergence of the individual, shouted the AMA Journal editor in 1926, in Great Practitioners, the editor thought, feared replacement of the human profession of medicine by organized medical department store or factory mechanicians.38

Rather than preference for private enterprise, or a business frame of mind, the essential basis of opposition to health insurance among the medical profession was fear of rationalizing and institutionalizing medical organization. As in the case of social workers, the struggle for the medical man was between a personal, relational approach and an institutional one. Healing of the sick is a very personal matter and best accomplished by the individual, wrote Ocshner of Chicago, in words that echoed many similar statements. By contrast, passage of the AALL bill would, in the words of Delphey, revolutionalize the practice of medicine so that the physician will professionally cease to be an individualist and will not be but a cog in a great medical machine. The idea of a personal relationship enabled the physician to view himself in the loftiest terms, while that of being a functional part in an organizational whole seemed degrading. Medicine was a part of a revolution that was occurring in social organization, observed AMA president Dr. William Allen Pusey of Chicago in 1924. There was an evident tendency to take medicine from the individuals responsibilities and to transfer it to the state and to organized movements. If this movement should prevail to its logical limits, Pusey warned, medicine would cease to be a liberal profession and would degenerate into a guild of dependent employees.39

In 1926 the editor of the AMA Journal expressed similar presuppositions, and waxed even more loftily mystical. The intimate personal relationship of patient and physician was absolutely essential because it reached not only the body but the mindthe soul, perhapsof the invalid, he effused. Once upon a time the priest had acted as a doctor. Tomorrow the doctor may well have become the priest. He would be a humanist, a man with the widest possible understanding of human motives. He will be a cultured man, ripe in intellectual attainments, but not lacking in emotional sympathy, a lover of the arts as well as a student of the sciences. It was a brave vision the editor had of the doctor, so god-like that it seemed consistent with his lofty vision at the opening of the same editorial of physicians occupying a place in the same cosmic scheme. But it was a tarnished vision, for it was in the same piece that the editor, very human like, delivered his name-calling tantrum against group practice, insurance, and state medicine.40

Stripped of the profession's self-adulation, the struggle was essentially that between the relational and the institutional concepts of social organization and status.

The discussion of health insurance had stagnated in the early 1920s, but it had not died. Beginning about 1926 the advocates of medical re-organization and insurance took it into a new, more active phase that lasted through 1935. Hostilities were even sharper than from 1915 to 1920, for the medical profession and the AMA were more alert in opposition, while the reformers had behind them support of some of the nation's wealthiest philanthropic foundations--the Milbank Memorial and the Julius Rosenwald Funds, the Russell Sage and the Rockefeller Foundations, the Carnegie Corporation, and others. The new phase differed from the old also in that the reformers within the medical profession adopted a stance that was politically and socially more cautious. In 1928 even Micheal Davis, now Medical Director of the Julius Rosenwald Fund, disavowed any affinity for a machine-made or standardized medical plan, declaring that medicines problems are not to be solved by the panacea of some universal legislative scheme of state insurance."41 The two phases were similar, however, in that both intertwined the health insurance issue with that of medical reorganization. .

A great deal of mutual suspicion and bitterness underlay the 1927-1935 discussions, regardless of how gentlemenly the protagonists appeared. A 1929 address by Edwin Embree, President of the Julius Rosenwald Fund, was symptomatic, both in substance and in tone. Society was becoming more interdependent and organized, Embree argued, and it was foolish to speak as if medical men could escape the historical trend. Already medicine had become more organized in its system of education, its public health efforts, and in the growth of hospitals and clinics. Yet the public was unhappy because such medical reorganization had scarcely benefitted the middle class. County medical societies fought the new clinics as if medical practice were the doctors' property. The public, Embree warned insultingly, was beginning to suspect that many of the doctors who oppose what they call unfair competition of hospitals and clinics are men who do not succeed very well when they have a chance to work in these institutions.42

The AMA Journal, long wary of philanthropic foundations meddling in the medical field with their vast financial power under non-medical control, replied to Embree's insults in kind, Sarcasm, half-baked opinions, and sops to the multitude, shot back the Journal's editor. He went on to charge Embree with ignoring the fact that medical attention was expensive because of x-rays, nursing services, laboratory work, specialists attention, and hospital care--not because of the physician's bill. His charge was specious. Although Embree had not made the point explicitly, advocates of medical reorganization and health insurance rested their cane finally on the precise point that modern medical advances had widened the gap between services available and ability to pay. And although the editor had admitted implicitly that there was problem of rising medical costs, he offered absolutely no economic solutions.43 Such was the level to which much of the discussion had fallen.

Beneath all acrimony and speciousness, the fundamental issue continued. The physician had a personal responsibility for the patient's well-being, the editor asserted, and if organization and slightly lower costs are achieved at the risk of disturbing the personal relationship between physician and patient in such a way as to mechanize medical practice, the gain will be a futile one. After further denunciation of the way in which the economists, the merchants, the brokers and bankers and the executive secretaries would make medicine a business without a heart, the editor predicted that the patients would suffer much under medical reorganization, unless they too have degenerated into robots.44 The issue was the hoary social assumption that people's welfare was better protected by a relationship of dependence upon persons of superior knowledge and wisdom than by carefully structured institutional arrangements.

The foundations' major influence was through their support of the research and publishing efforts of a Committee on the Costs of Medical Care from 1927 to 1932. The CCMC was a private group of forty-five to fifty citizens, one-fourth to one-third of them physicians in private practice, and the remainder dentists, nurses, social workers, economists, public representatives, and physicians connected with hospitals, public health departments, and other organizations. Reform-minded, it gradually produced a two-foot shelf of literature on a variety of topics mostly related to organization of medical practice and payment, and then in 1932 issued its final reports. The most central recommendation of the 35-member CCMC majority was that medical practice be reorganized around a system of health centers under local community control: in large cities, units offering complete hospital and out-patient facilities, laboratories, pharmacies, etc.; in smaller cities, scaled-down versions affiliated with large city units so as to have complete access to the more specialized services; and in rural areas substations of the larger units.45

As a corollary to its plan for reorganizing practice on a group basis, the CCMC majority recommended group payment . . . through the use of insurance, taxation, or both. By insurance it meant not national or state compulsory systems, but locally-organized voluntary cooperative health insurance. Its plan was for industrial, fraternal, educational, or other reasonably cohesive groups of medical consumers to arrange with hospitals, medical centers or private clinics to obtain medical service in return for fixed weekly or monthly payments. For families too poor to pay even such smoothed-out medical fees, the majority thought that the local community may well wish to make part or all of the payment from tax funds; and where an entire community was economically depressed, it recommended state aid. Eight members of the majority wanted to go furthur and make health insurance required (compulsory had bad connotations) for low-income groups, but the other twenty-seven demurred.46 Their demurrer reflected the social and political conservatism in the majority's assumptions.

The reformers on the CCMC directed their efforts less toward helping the poor than had reformers in 1915. Although it had gradually become clear to some that insurance based on payroll contributions would not serve the very poorest, the health insurance campaign of 1915 to 1920 had begun as part of a much larger movement to prevent and relieve poverty. From 1927 to 1932,by contrast the reformers focused on the patient of moderate means, who supposedly was too proud to avail himself of the excellent facilities that hospitals and dispensaries offered to the poor on a charity basis, and not wealthy enough to buy such care. In recommending voluntary rather than compulsory insurance the CCMC majority admitted that voluntary systems had been ineffective for reaching low income families in foreign countries. It recognized also that, with voluntarism, insurance alone could not effectively shift the financial burden of medical care from the poor to the more well-to-do, to make greater medical resources automatically available to the classes most in need of them. It was satisfied to leave subsidization on a case-by-case basis, at the discretion of local authorities.47

That the CCMC majority did not conceive of health insurance as a device first of all for meeting the problem of poverty was evident also in its concern for quality rather than for wide spread availability of medical services. In the earlier phase, from 1915 to 1920, health insurance advocates had begun their campaign as an effort to make medical care much more widely available through redistribution of medical costs. Only later had medical reorganizers seized upon the movement to foster their plans for improving medical facilities. But the movement that revived in 1927 was one essentially to improve medical facilities. Questions of distributing costs were important, but somewhat incidental. Explaining its reluctance to recommend a broad compulsory system of health insurance, the CCMC majority declared that it was much more important to establish a system that would provide a considerable part of the population with complete and competent medical care, hoping gradually to extend medical service of high quality to more and more people, than to devise a plan that would cover more people immediately but provide service that was less complete and lower in quality.48 In so saying it stayed within a strong, elitist tradition in the profession that gave infinitely higher priority to quality of medical care than to quantity, or to its ready accessibility to all people.

Above all, declared the CCMC majority, compulsory health insurance should await the evolution of group practice units capable of rendering rounded medical service of high quality. Once more reformers tied the health insurance question to that of medical reorganization, although at one point Davis warned against it. The direct application of the principle of insurance to sickness means to distribute the financial burden, not to reorganize medical service, he warned in 1930. The issues of finance in the problem of sickness must be largely separated from those which directly concern the professional services.49 Had the CCMC built upon that premise, prospects would have been brighter for rationalizing at least the financial basis of medicine and easing medical burdens for low income classes through health insurance. But it did not. It kept the two issues once more so hopelessly intertwined as to make it nearly impossible to get a hearing for health insurance on its own merits.

The chief dissenting minority of the CCMC came nearer to separating the insurance and general reorganization issues than did the majority. Eight physicians and one medical educator entered a separate report that rejected out of hand the majority's recommendations for reorganizing medical services around community medical centers and group practice. To them reorganization raised the specters of bureaucracies, hierarchies, and dictatorships, and of depersonalized, mass-production methods. The medical profession, not forms of organization, was the essential element in medical care, they argued. And the essential element of the profession was the general practitioner, who could function effectively only through the maintenance of private medical practice. Their central recommendation, then, was that united attempts be made to restore the general practitioner to the central place in medical practice.50 Yet they did not reject the idea of health insurance absolutely.

At least the minority professed to favor health insurance in principle. In practice it gave many more arguments against it than for it. First it denounced the voluntary insurance that the majority had recommended, saying that voluntary schemes had failed in European countries, and that pilot plans in the United States possessed all the evils of contract practicesolicitation of patients, destructive competition among professional groups, inferior medical service, loss of personal relationship of patient and physician, and demoralization of the professions. Then it declared that the objections to compulsory health insurance are almost as compelling, for the same evils had appeared in the administration of workmen's compensation. Yet the minority declared that we are not opposed to insurance but only to the abuses and evils that have practically always accompanied insurance medicine. The majority should have used its energies to warn against contract forms of practice. And if there were to be group payment plans, they should be under the auspices of county medical societies, and have built into them a series of safeguards that included having the community, through tax funds or charity, pay doctors for care of indigents; use of insurance to cover only that part of the medical bill that exceeded the patient's means; and virtually complete control by the medical profession. 51

Thus the CCMC minority divorced the health insurance question from the issue of medical reorganization, but tied it instead to the question of control by medical associations. The majority, it complained, had failed to come to the assistance of the medical profession in a battle against forces which threaten to destroy its ideals, disrupt its organization and completely commercialize its practice. The AMA Journal, discussing the CCMC reports, put the issue more bluntly. The majority, it charged, had virtually ignored the fact that the various elements of the medical profession were already professionally organized in their own associations.52

The Journal's position on the CCMC minority's health insurance recommendations was somewhat contradictory. It urged support of the minority report, whose signers had included Dr. Olin West, the AMA's Secretary and General Manager; Dr. George Follansbee, Chairman of the Association's Judicial Council; and Dr. Malcolm L. Harris, a President of the AMA in 1928-1929. The alinement is clear--,22 declared the Journal, on the one side the forces representing the great foundations, public health officialdom, social theory--even socialism and communism--inciting to revolution; on the other side the organized medical profession . . . urging an orderly evolution guided by controlled experimentation which will observe the principles that have been found through the centuries to be necessary to the sound practice of medicine. and which would not practice one kind of medicine for the rich, another for the poor. But its support was primarily for the minority's rejection of medical reorganization. The CCMC majority, it implied, had gone mad over efficiency systems, organization, and standardization. On the question of group payment, it omitted any specific endorsement of county medical societies formulating such plans. Moreover, where the CCMC minority had specified that any plan should be non-profit, the Journal, suggested that the individual patient buy a commercial insurance policy of a type that did not interfere with free choice and the personal relationship between physician and patient.53

In 1930 the AMA had created its own Bureau of Medical Economics to undertake research parallel to that of the CCMC. Gradually the Bureau collected nearly every argument ever made against health insurance (or sickness insurance, as opponents preferred to call it). Its indictments applied most directly to compulsory systems; but voluntary plans were no better, because every voluntary system tends to become compulsory. Once compulsory, social insurance became an instrument for the compulsory redistribution of the income of its members, which in turn made it a matter of political controversy. In fact, the Bureau asserted, sickness insurance almost always began as a device of politicians, not because the workers who were supposed to benefit demanded it. It right even do positive harm to workers, by lowering the standards of medical care, and by inducing in them a kind of insurance neurosis whereby they wanted to be sick in order to be indulged with care or to get a return on their insurance premium. As an institution sickness insurance rested on a doubtful actuarial base, always lost any democratic character as a given system grew in size, remained experimental and complex, and required constant tinkering and change even where it had existed for a half-century.54

In its panoply of indictments, the AMA Bureau once again tied the health insurance issue to the question of control. It argued that insurance carriers in other countries tended to become more interested in the prestige of their institutions than in peoples welfare, gradually got the power to license physicians, and used their organizations as power bases from which to fight the medical profession. Unlike the CCMC minority, however, the Bureau left the health insurance issue tied also to that of medical reorganization. Running through its arguments was the old conflict between a personalized, relational approach and an institutional one. It constantly emphasized the preservation of the personal relationship between physician and patient. At the outset of a major report in the spring of 1934 it declared that social insurance in general was the result of a compulsory urge to organization and had its origin in the mechanical conception of life. Sickness insurance in particular, it concluded near the end of the same report, is one phase of the effort of industrial civilization to force a recalcitrant profession into industrial patterns.55

The AMA did not represent all in the medical field. For a time it appeared that organized dentistry might be more friendly to health insurance. In 1930 the American College of Dentists appropriated $16,000 to underwrite a CCMC study of European social insurance, and it remained open on the issue throughout the entire period. In the same year the American Dental Association appointed a committee to cooperate with the CCMC, and made a stanch advocate of health insurance, Dr. Herbert E. Phillips of Chicago, its chairman. Phillips and another member of his committee, Dr. C. E. Rudolph of Minneapolis, were members of the CCMC, and in 1932 submitted their own minority report favoring both compulsory health insurance and group practice, though they wanted reorganization of practice to be through the professional associations. But in 1931 the ADA repudiated its Phillips committee. Shortly before the 1932 ADA annual meeting the editor of the ADA Journal challenged the claims of reformers that only 20 to 30 per cent of the populace ever received dental care beyond extraction of teeth, and then added the amazing statement that even if it were [true], I see no need for the profession to get so wrought up about it. At the 1932 meeting the association elected a president, G. Walter Dittmar, of Chicago, on a platform of dentistry for dentists and of protecting dentists interests against will-of-the wisps such as panel dentistry, insurance dentistry, state control, low fee clinics, corporation dentistry, etc.56 Thereafter the ADA was fully as cautious about any reforms as was the AMA.

Other groups even closer to the physicians defected permanently. In 1932 The American Journal of Nursing endorsed the CCMC majority report, declaring that nursing was tenable only on a cooperative basis and that therefore nurses welcomed the movement for more closely knit medical services and for provision through insurance of such services. In June of 1934 the Regents of the American College of Surgeons adopted resolutions supporting experimentation with various periodic prepayment plans designed for individuals and families of moderate means, provided they remained free of commercialization, protected free choice, and were under the medical profession's control. As from 1915-1920, hospital men also entertained much sentiment for insurance. Within the American Hospital Association Winford Smith, Director of Johns Hopkins Hospital and one of the founders of the CCMC, wanted to go beyond the CCMC majority and support compulsory insurance (he was one of the eight members of the CCMC majority who took that position in 1932). But no less a figure than Sigismund S. Goldwater of New York, a foremost champion of the AALL bill from 1915 to 1920, demurred. Goldwater took the position that compulsory systems were for the benefit primarily of low-income working men who already had access to free hospital care, and that for the patient of moderate means voluntary health insurance unhampered by state regulation was probably the answer. In 1933 the Hospital Association strongly endorsed group hospitalization insurance. Its rationale was at least as cautious as that of the CCMC majority: that the adoption of some plan which would distribute the costs of sickness and benefit the sick individual would be one of the most effective ways to offset the increasing demand for more radical and potentially dangerous forms of national or state medicine.57 But even in its conservatism, the Hospital Association was, like the nurses and the surgeons, more favorable to the idea of health insurance than was the AMA.

On June 8, 1934, U. S. President Franklin D. Roosevelt announced the formation of a cabinet Committee on Economic Security to take up the question of social insurance. Several days later the AMA met for its annual sessions. Before it were a resolution from the Michigan Medical Association that the AMA restudy its position on health insurance, and, in the words of an AMA committee, other manifestations of unrest in relationship to the economic situation among some of the component and constituent bodies of this association. In the face of Roosevelt's previous political successes and of disunity within the larger medical profession, the convention drew back from outright condemnation of health insurance. Instead it put forward ten principles that any plan should observe:

1. Every feature of medical service to be under the control of the medical profession.

2. No third party to be allowed to interfere with medical relations between physician and patient.

3. Free choice for the patient from among all doctors of medicine qualified to practice and willing to serve.

4. Maintenance of a permanent, confidential relation between the patient and a family physician as the fundamental and dominating feature.

5. Because every feature of medical service was to be under control of the medical profession, separate treatment of hospital and medical service--with hospitals seen as expansions of the equipment of the physician, subject to his judgments as to adequacy and character.

6. However the cost of medical service may be distributed, the immediate cost. . . [to] be borne by the patient if able to pay at the time the service is rendered.

7. Separation of medical service from cash benefits.

8. Inclusion of all qualified physicians in a locality who wished to participate.

9. Systems for the relief of low income classes . . . limited strictly to those below the comfort level standard of incomes.

10. The entire power to formulate and enforce restrictions on treatment and prescription to be in the hands of the organized medical profession.58

Principles 6, 7, and 9 were recommendations in effect to keep the application of the insurance mechanism at a minimum; to separate administration of insurance as far as possible from medical service, even to the point of making the patient rather than the insurance fund liable for the physician's payment; and not to use the insurance mechanism to shift resources to those unable, even when the cost was smoothed out, to pay the full cost of their medical care--i.e ., not to use insurance to redistribute wealth. The ten points together were an elaboration of eight points which the CCMC minority had offered as safeguards in 1932, and breathed the principles of the minority report: if health insurance must came, let it serve to strengthen the general practitioner and the medical associations, be tied to their control, and reorganize their practice as little as possible.

Having set forth its conditions, the AMA wavered between non-cooperation and cooperation with the Committee on Economic Security, When the CES appointed Edgar L, Sydenstricker, Director of Medical Research for the Milbank Memorial Fund, and Isador S, Falk, his associate, to conduct its medical studies, the AMA Journal responded with a bitter editorial. Sydenstricker was a supporter of medical reorganization and health insurance from the 1915-1920 campaign, and as a member of the CCMC had rejected the majority report in a personal statement charging that the Committee had ignored underlying economic problems. Now the AMA attacked him personally, saying that under him and Falk nobody could expect recognition of the medical point of view. Sydenstricker, the Journal noted, had criticized the American economic systems grossly unequal distribution of wealth. And he favored a health insurance system even more radical and complete then foreign systems. The CES decided to turn the other cheek. It added Roscoe G, Leland and Algie M. Simons of the AMA's Bureau of Medical Economics to its staff, consented to extend the deadline far a report or, medical matters beyond. that for the rest of its program, and made other conciliatory gestures. Thereafter the Journal struck a cooperative note. It even chided physicians who were beseiging AMA offices with telephone calls and telegrams for being opposed to all change, Although the AMA stood firm against socialization of medical practice, the Journal pointed out, its June meeting had endorsed properly Controlled experimentation with new forms of medical practice.59

When in January of 1935 Roosevelt presented his economic security program, the Journal maintained its equanimity. The medical reports having been delayed, the program did not include a firm proposal for health insurance, but merely set forth eleven principles to be observed in constructing a health insurance system. The Journal noted that the eleven points strongly reflected the AMA's ten and that they included such crucial considerations as the importance of sustaining quality of medical service, professional responsibility in administering medical care, free choice of physician and institution, exclusion of commercialism, and continuance of private practice.60 On the surface it appeared that perhaps this time the CES had sufficiently separated health insurance from medical reorganization to win at least the passive acquiescence of physicians.

But not, apparently, am the minds of most physicians, or at least of their representatives in the AMA governing body, the House of Delegates. The AMA Board of Trustees convened a special session of the House in February, and presented to them a history of the health insurance issue that once again intertwined it with the issue of medical reorganization. Its report noted that despite the absence of health insurance in the economic security bill the CES had recommended it in principle as one solution to the medical problems of low-income families. The CES's eleven points now became, instead of a source of reassurance, damning evidence that the government actually meant to formulate a health insurance system, After a stormy session the delegates responded in kind and adopted a statement, that began with the idea that regimentation of the medical profession and lay control of medical practice will be fatal to medical progress and inevitably lower the quality of medical services now available. The delegates went on to score the CES for recommending a social insurance board without specifying that it must include persons with medical training to oversee medical programs. They gave their blessing to voluntary hospitalization insurance, but specified that it must be kept entirely separate from payments to the doctor for his services. For spreading the burden of the doctors fees they encouraged only the crudest devices: voluntary group prepayment plans and installment purchase. Voluntary budgeting to meet the costs of illness, it called its recommendation--a phrase which like the idea of installment payments totally ignored the need for a social mechanism to spread costs from person to person. Even less did it contemplate using insurance to shift costs from the poor to the more well-to-do. Moreover, it encouraged such plans only where local medical organizations established them. Beyond that the House of Delegates officially reaffirmed its opposition to all forms of compulsory sickness insurance whether administered by the federal government, the governments of the individual states or by any individual industry, community or similar body. Shortly thereafter the trustees of American Dental Association concurred in the AMAs position.61

Sydenstricker finally despaired of paying too much attention to this group of reactionary politicians and of seeing Roosevelt licked by a group of doctors. He and Falk urged the CES to move ahead and recommended a federal tax and subsidies designed to induce state legislatures to formulate health insurance systems. The CES was inclined to approve, but Roosevelt wished to wait, so as not to jeopardize the rest of the social security program. Roosevelt withheld his approval indefinitely, and the battle for health insurance was lost.62

Convinced of the righteousness of our attitude, knowing that the medical profession alone understands the fundamental human factors at the basis of the best medical care, it is our duty to do our utmost to make our point of view prevail, declared the editor of the AMA Journal in January of 1935. The professions haughtiness had elements that were admirable, and others not so admirable. It included a brave vision of a profession that would make men broadly humanistic, liberal in the classic sense, and priestly, rather than reducing them to mere high class technicians and functionaries, But it also had blind spots: the inability to admit that doctors were no more omniscient than other men, or that a professional perspective and concern for prestige and money could make their outlook provincial; failure to perceive that a humanistic elitism might not necessarily equip them best to fulfill the social responsibilities of their profession; and refusal to give much weight to considerations of economic availability in their criteria for high standards of medical care--to consider quantity as well as quality. Nearly always, the blind spots lay in the shadows of a highly personalized conception of medical practice. Medicine and medical institutions alike stand at the sharp division between two merging types of civilization, wrote Dr. Charles Gordon Heyd, Professor of Surgery at the New York Post-Graduate Medical School and-Hospital, in 1929, --an old system built up by individual contributions, and a new system made up of . . . contributions by organized efforts.63 In the case of health insurance the conflict between a personal, relational approach to welfare and a rationalized, organized, institutionalized one took place not only at the levels of social theory and engineering, but within the doctors' very souls.

11 Report of Committee on Social Insurance (1916; cited note 3); Report of Committee on Social Insurance (1917; cited note 3); Report of the Committee on Social Insurance of the American Academy of Medicine (cited note 4).

37 Arthur Krida, Health Insurance from the Public Health Viewpoint, New York Journal of Medicine, 17 (Mar., 1917), 136; John Franklin Crowell, Social Insurance, with Special Reference to Compulsory Health Insurance: A Report Prepared for the Committee on Insurance of the Chamber of Commerce of The State of New York (New York, 1917), 41; Delphey, Arguments Against the Standard Bill (cited note 6), 1501; Group Practice--A Menace or a Blessing? AMA Journal, 76 (Feb. 12, 1921), 452-53.

45 For the kind of analysis and assumptions with which the CCMC approached its task, see Harry H. Moore, American Medicine and the People's Health (New York and London, 1927); in its introduction the book is warmly endorsed by a committee of five who organized the CCMC. Committee on the Costs of Medical Care, The Final Report of the Committee on the Costs of Medical Care (CCMC publication no. 28; Chicago, 1932) 59-71, 108 -18.

56 Bissell B. Palmer, The Adequate Health-Service Movement, The Journal of the American College of Dentists, 2 (Apr.-July, 1935), 88 Reports of Standing Committees, New Orleans Convocation, November 3, 1935; XI. Socio-Economics, The Journal of the American College of Dentists, 3 (Mar.-June, 1936), 75-77; The Committee on the Cost of Medical Care, The Journal of the American Dental Association, 17 (Jan., 1930), 146; CCMC, Final Report, 184--88; Herbert E. Phillips, Health Insurance, Clinics, Corporate or Contract Practice and Resulting Organization Problems, of The Journal the American Dental Association, 20 (Jan., 1933), 67, 79-80.

57 Confronting the Peril of Taking Thought, The American Journal of Nursing, 32 (Dec.,1932), 1295; I. S. Falk, Security Against Sickness: A Study of Health Insurance (Garden City, N. Y., 1936) , 370-74, 376-77; Winford H. Smith, Hospitals and Their Part in the Program of the Committee on the Costs of Medical Care, Transactions of the American Hospital Association, 34 (1932), 388-95; CCMC, Final Report, 121, 130-32; Goldwater, The Problems of the Patient of Moderate Means, Transactions of the American Hospital Association, 32 (1930), 426.

58 Proceedings of the Cleveland Session: Minutes of the Eighty-Fifth Annual Session of the American Medical Association. . .Report of Special Committee, AMA Journal, 102 (June 30, 1934), 2199-2200.